How to Appeal a Anthem Blue Cross Blue Shield Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology Denial

What Anthem Blue Cross Blue Shield requires for coverage

Anthem Blue Cross Blue Shield considers Rehabilitative and Habilitative Services in the Home Setting: Physical Medicine/Physical Therapy, Occupational Therapy and Speech-Language Pathology medically necessary when the following criteria (from CG-REHAB-12) are met:

• The therapy request satisfies medical necessity standards under the plan's applicable physical, occupational, or speech-language pathology guidelines
• The request meets home health care medical necessity criteria outlined in CG-MED-23
• BOTH conditions above must be met simultaneously

Covered procedure codes

How to appeal this denial

Frame your appeal around the specific criterion you satisfy. Quote the CG-REHAB-12 language above, then show — with your physician's records and clinical evidence — exactly how your situation meets it. Demand that Anthem Blue Cross Blue Shield either approve the claim or identify the precise criterion they believe you fail. CareCost Appeals assembles this automatically: it cites the policy, pulls verified clinical evidence, and applies your state and federal appeal rights.

Source: Anthem Blue Cross Blue Shield medical policy CG-REHAB-12 — view the published policy.